Shining a Light on Men’s Dental Health – By Dr. Steven Swidler
A quick internet search on “men and dental health” will show that men are simply less likely to take care of their teeth and gums. With all the hard scientific dental data available linking dental issues with major health conditions such as heart disease, strokes, compromised immune systems and more, men still tend to procrastinate far more than women when it comes to their oral health.
According to new research in the Journal of Periodontology, men are almost twice as likely to completely ignore this important and often overlooked segment of our health and well-being. The National Institutes of Health says that dentists are in a unique position to identify a host of issues and early signs of ailments, such as rheumatoid arthritis, acid reflux (exponentially accelerates tooth erosion), oral cancer, celiac disease (leads to tooth discoloration, spots, banded/grooved look on teeth), osteoporosis, increased risk of heart attack and stroke and more.
Men increase their odds of having major dental problems over women due to specifics such as putting pain off, less homecare attention, being on more medications than women (many of which can lead to dry mouth), contact sports or physical hobbies, increased tobacco use (especially chewing tobacco), and maybe some good old-fashioned pride/avoidance. As a result, men have more plaque, more bleeding and swollen gums, bad breath, fewer teeth and far more trouble with their bite. Statistics support that men are on more medications, and a result of many meds is less saliva, which makes for a dry mouth. We need saliva to wash cavity-causing bacteria away. Men are also more likely to develop throat, tongue and other mouth cancers.
While it is difficult for the experts to be conclusive about what percent of the above conditions are dentally induced, we know from extensive research they most certainly are dentally involved. There are excellent products, dentists and information out there to support men with the increasingly growing gap of health issues related to dental avoidance. Procrastinating invites far greater costs, pain and side effects. Consistent monitoring with a dental professional, proper homecare and addressing any problems early on can save tens of thousands of dollars.
Holistic dentistry focuses on overall wellness as a standard practice, from material testing to alternative approaches to gum problems. A holistic dentist can remove toxic mercury/amalgam fillings safely. They provide noninvasive approaches to TMJ, which affects one’s bite, and as a result, their entire structural alignment. TMJ symptoms are accelerated even more by stress, clenching or an overlooked imbalance.
It is not recommended to exceed six months between dental visits (sooner if something is wrong), but we are individuals. What works for one person may not be the same for the next. Therefore, it is important to locate a dental office where we feel comfortable and our unique needs are acknowledged, as it is a cooperative effort to achieve and maintain dental and overall health.
Having and maintaining daily oral health practices is a key to a long healthy life for both sexes, even if it is not our favorite thing to do as males. Putting dentistry off simply costs more. It costs our health, our vitality, our confidence and therefore our quality of life.
Medicine Wheel Dental & Wellness Center is located at 4650 W. Jojoba Dr., in Tucson. For more information, call 520-743-7101 or visit MedicineWheelDental.com. See ad, back cover.
Here’s the link to the article in Natural Awakenings
Holistically Fighting Gum Disease
By: Dr. Steven Swidler
A recently published dental bulletin states that, “almost all Americans, except the millions who already wear false teeth, have some form of gum disease.” Over the past decade, there has been mounting evidence that points to the relation of cardiovascular disease, stroke, atherosclerosis and vascular disease in patients with higher levels of gum—or periodontal—disease.
What Causes Periodontal Disease?
The mouth routinely harbors about 300 different varieties of bacteria, however it has been scientifically proven that the troublemakers are spirochetes, motile rods and cocci. If these nasty bugs can be reduced below certain levels, the body can heal itself.
Our teeth are encompassed by bone and attached to our gums by a periodontal ligament. A space, or crevice, just under the gum line, which is measurable and varies between 1 and 3 millimeters, is a natural hiding place for the hundreds of good and bad bacteria our mouths naturally harbor. When these bacteria are not cleansed routinely through tooth brushing, flossing, oil pulling and other cleansing techniques, a low-grade infection or gingivitis can occur.
Gingivitis is the beginning of a potentially harmful disease process which, if left untreated, can result in tooth loss and significantly increases the risk of cardiovascular disease. Swollen, bleeding gums harbor bacteria, which travels through the enlarged blood vessels through the blood stream and to the entire body, much of which has been proven to settle in the heart.
In understanding the etiology of gum disease, it is well to keep in mind that no two human beings are exactly alike. There is a wide variation in any individual’s resistive ability when it comes to fighting off gum disease. According to many studies, in a large sample of people whose general health would be considered good, a few would have such strong resistance that their gums and supportive bone stays healthy even if they were very neglectful of oral hygiene, eating habits and the like. Another small group would be highly prone even if they were very conscientious. A large group in the middle would suffer what might be called typical gum disease.
Some people will suffer from what could be called “magnified” gum problems. Gum disease can be exacerbated by many conditions, including stress, immunosuppression, malnutrition, endocrine abnormalities and mouth chemistry. Therefore, one who has been using all the right methods of eliminating the cause of gum disease, yet still having problems, should analyze the possibility of some intrinsic factor that might be complicating the overall health picture.
Being treated medically for any number of problems can also have side effects complicating the gum disease situation. For example, about 500 different commercially prepared drugs can cause a reduction in the amount of saliva flow. Reduced salivary flow can have an extremely damaging effect on the teeth, gums and supportive bone.
Minimizing or Reversing Periodontal Disease
Part of the solution lies in cleansing this crevice of the toxic waste products from harmful bacteria. Brushing and flossing are just part of a healthy dental routine. A healthy and effective alternative to toothpaste is a do-it-yourself toothpaste remedy that has been around for decades. Take equal parts of salt and baking soda in a “dipping bowl” and, using a damp toothbrush, dip into the powder mixture and brush. You may need to reapply as necessary. This technique might be a bit messy and not taste great, but will do wonders for decreasing the biofilm buildup and inflammation associated with early stage periodontal disease. This oral hygiene method can be included a few times per week as a maintenance or preventive means to battle gum disease.
Holistic dentistry focuses on treating the whole body and not just the symptoms, as with mainstream health care, so it is no surprise that the discipline stresses good nutrition and gut health—key factors among those that enjoy freedom from dental problems. Teeth, like bones, are made up of primarily calcium and phosphorus. Individuals, who, at any time in their lives, have been shortchanged of these two valuable elements in their diet, will most likely suffer a degree of adverse dental effects, such as soft teeth or weak bone support for the roots.
The saliva that is produced for us by glands in and around the mouth contains calcium and phosphorus in solution, along with various enzymes. The calcium and phosphorus ions help to keep teeth strong by depositing themselves in the outer layers of the teeth. Therefore, under the right conditions, teeth are constantly being hardened or mineralized.
The key to avoiding the effects of most types of gum disease in human beings should include a multifactorial approach, outlined below.
• A focus on proper nutrition and gastrointestinal health, to decrease overall inflammation and immune issues
• Test and monitor mouth alkalinity/acidity
• A consistent and thorough oral hygiene program including, but not limited to, brushing, flossing, use of a Waterpik and in many cases, oil pulling
• Smoking cessation
• Safe and effective home care products
• Drinking plenty of water
• Brush teeth or swish with water immediately after eating highly acidic foods or drinking lemon water
• Regular hygiene and dental check-ups
It’s that time again! You just received that friendly reminder call
from your dental office, reminding you its time to have your teeth cleaned.
Some of us are happy knowing our appointment is already scheduled, while
others begrudgingly oblige because we know it’s “good for us,” and others of
us put it off as long as possible. No matter how you feel about having your
teeth cleaned, the benefits go far beyond what many of us are aware of.
Sure, we all know having our teeth cleaned helps with whiter teeth
and fresher breath, and we all love that “fresh from the dentist clean”
feeling. However, the underlying benefits of having your teeth cleaned go
far beyond what you can see and feel in your mouth. In fact, having your
teeth cleaned regularly not only maintains your oral health, but also has a
significant impact on maintaining your overall health.
Hidden Benefits to having regular teeth cleanings:
*Prevent Heart Attack and Stroke
Having your teeth cleaned involves removing plaque and tartar that
adheres to your teeth, both above and below the gumline. Both plaque and
tartar harbor bacteria, which in high enough concentration, causes an
infection in your gums. As with anywhere else in the body, when an
infection is present, inflammation occurs. When inflammation occurs in the
gums we refer to it as gingivitis. If the infection is left untreated, the
bacteria continues to thrive and multiply eventually causing damage to the
bone structure that supports the teeth. This is called periodontal disease.
Several studies have shown a link between both heart disease and
stroke. When the tissues in the oral cavity are inflamed, they bleed
easily. When the gums bleed, the bacteria in the area have a freeway
entrance into the blood stream and entire body. There have been documented
cases of both dental plaque build up and dental bacteria present in arterial
walls. For this reason, periodontal disease has been found to be a risk
factor for both cardiovascular disease and stroke.
*Prevent Oral Cancer
The Oral Cancer Foundation states that in the United States, someone
dies every hour of the day from oral cancer. During every cleaning
appointment, a thorough oral cancer screening is performed. Any abnormality
can be addressed early and possibly avoid progression into cancerous cells.
Early diagnosis of oral cancer is the best prevention, in that, if caught
early, oral cancer has a very good prognosis.
It’s no secret that when dental treatment is needed, as with most
things, if dealt with early, you can almost always save time and money.
Allowing an infection or broken tooth to go untreated will only cost more
money and effort to fix in the long run. If there are dental problems
present, being seen regularly can detect them when they are at an early
stage. Not only does this save time and money, but has the potential of
preventing severe pain somewhere down the road.
*Healthy Pregnancy and Childhood
Inflammation of the gums caused by the bacteria in plaque and tartar
has another unseen complication. Both gingivitis and periodontal disease
can contribute to unhealthy pregnancy. Gum disease has been marked as a
risk factor for both pre term labor, as well as low birth weight babies.
The long term complications of low birth weight babies are extensive, and
can sometime be prevented just by maintaining a healthy oral environment
during pregnancy. Pregnancy hormones in turn can have a detrimental affect
on the health of gum tissue, which can be remedied by regular dental care.
Another risk to children associated with high levels of bacteria
present in their parent’s mouths, comes from what many parents do without a
second thought. The simple action of sharing a bite of food with your
children, has been shown to contribute to higher decay rates in children.
By sharing utensils, bacteria is passed from one to another. By maintaining
a healthy mouth, the amount of bacteria available to be “shared” is
significantly reduced and therefore reduces the risk for both cavities and
gum disease in younger children.
There are many more unrealized benefits to maintaining a healthy
oral cavity, even including lowering the risks of diabetes. So, while many
of us may not love the idea of seeing the dentist or hygienist, the benefits
go far beyond that “fresh from the dentist feel.” By having regular dental
cleanings, you are not only maintaining a healthy smile, but you are
contributing to an overall healthy YOU!
De Elise Krause, RDH
Medicine Wheel Dental and Wellness Center was featured in the January 2013,
Tucson Natural Awakenings Magazine.
Reinventing the Wheel
Dr. Steven Swidler and his team break the mold of traditional dentistry with remarkable innovations in holistic care and a diverse new wellness center.
Although the acronym DDS that follows his name stands for doctor of dental surgery, Dr. Steven Swidler, of Medicine Wheel Dental and Wellness Center, in Tucson, is not your typical dentist.
You can read it here Natural Awakenings Article, January, 2013
Silver Fillings May Cause Memory Loss & Mood Swings
Before other options were available a trip to the Dentist often resulted in silver fillings as a result of any cavities that you may have had. On March 28, 2013 Dr. Oz will be talking about silver fillings and the effects that they may be having on your health. Should you consider having your silver fillings replaced and what potential risks may they be having on your health.
Dr. Oz will be inviting on experts in the field to talk about silver fillings and what health issues they may be causing. Can they cause memory loss or mood swings? What are the long term risks and what risk factors and symptoms may become noticeable that may be a signal that your silver fillings may be the culprit behind what has been making you sick. If you have been experiencing unexplained symptoms for years and investigating all sorts of ailments, the problems may have been literally lying in your mouth all along. If you or someone you love still has silver fillings the Dr. Oz March 28, 2013 show will definitely be an episode that you will absolutely not want to miss.
Are Silver Fillings Toxic?
Dr. Oz will be talking about why silver fillings are toxic to your health and why they may be causing health issues like memory loss, mood swings, as well as a wide variety of other symptoms. Silver fillings contain high levels of mercury which have been shown to be harmful to your central nervous system as well as cause a wide assortment of other health ailments. Many countries have banned silver fillings and Dr. Oz will be inviting experts on to the show that will be bringing you the facts about what you need to know.
Guests To Be Included On The 3-28-2013 Dr. Oz Episode :
- Dr. Gerald Curatola
- Dr. Jonathan B. Levine
- Dr. Brent Moelleken
- Dr. Michael Niccole
- Dr. Alicia Salzer
Dr. Swidler developed an all natural 70 antioxidant treatment for deep decay and exposed nerves. There have been almost no treatments available to keep a tooth vital (alive) where decay has exposed the nerve. Other dental offices are able to save only 1%-2%, at best, often with severe pain following, so patients are recommended for an immediate root canal or extraction.
With our proprietary natural treatment, we have been able to “save” (keep alive) over 90% of the teeth with exposed nerves as long as two factors are observed:
- Red blood is seen (as opposed to a dead dry canal or pus)
- The anesthetic works to numb the tooth
Healthy teeth have a circulation of their own from the blood vessels within the tooth to the outside of the root through thousands of tiny tubules. Root canalled teeth are non-vital or dead teeth. No where else in medicine do we leave a dead part in the body. It would become gangrenous or infected and need to be removed. However, in dentistry we have been able to treat teeth with cleaning out and filling the inside of the tooth’s larger canals and pain is often eliminated on sensitive or painful teeth. Without pain, a person can keep chewing and functioning on these dead teeth. Being free of pain does not mean that the tooth may not still have a low grade chronic infection around or in it.
Teeth are not fused to the bone in which they sit. They are actually suspended by thousands of tiny ligaments in a suspension system that allows for tiny movement. This anatomy clearly indicates a space around an entire tooth’s roots so that when a tooth actually dies or abscesses, the infected tissue or pus has measurable bacteria, viruses and toxins circulating in that space on the outside of the root of the tooth. The research of Dr. Steinem showed that not only is there a circulation of ions in a healthy tooth from the inside to the outside through the tooth’s root but when a tooth dies, there is a “suck back” of ions and other material in that natural space (bacteria, toxins) from the end of the root tip of an infected tooth into the thousands of microtubules (tiny straws running between the inside and outside of the root) along the whole root surface.
Dr. Weston Price, when he was chief researcher for the ADA, did an unprecedented 25 year study involving 5000 rabbits, showed scientifically how dead root canal teeth harbor bacteria, viruses and toxins.
The study involved removing root canal teeth from people with specific diseases, surface sterilizing the dead tooth and implanting it under the skin of a rabbit. Within two weeks the rabbit developed exactly the same disease the person had (kidney disease, heart disease, etc.). While this “focal infection theory” has been resisted, it is now a well accepted fact that bacteria found in the mouth can travel directly to the heart if the gums are swollen or bleeding. Surgeons are insisting that gum (periodontal) health is established before surgeries to eliminate this pathway of focal infection.
Later, electron microscopy showed how the 30 micron diameter microtubules were harboring 4 to 5 micron bacteria and smaller viruses. In a molar tooth there are so many micro tubules that if you put them end to end you’d have a tube 2.5 to 3 miles long!! While antibiotics can be used to treat an abscessed/infected tooth, it only treats the body side of the equation. There is no longer any live circulation within the tooth and medications cannot reach into the tubules.
Root Canal specialists take great care to seal the large main root canals within a tooth and seal the end of the root, but have no ability to eliminate the bacteria, viruses and toxins from the infection spreading from the end of the root through the large ligament space around the whole outside of the root.
ALT testing developed by Dr. Boyd Haley at the University of Kentucky measured the proteins and toxins associated with infected teeth. They could be detected and measured all the way from the root tip to the gum line of the infected tooth.
At Medicine Wheel are very pleased to offer the first effective treatment to avoid root canal treatment and keep teeth alive. Remember, the key is to treat these teeth as quickly as possible before the tooth’s nerve dies.
At Medicine Wheel Dental & Wellness Center we made the conscious choice long ago that we would not subscribe to any particular dental insurance company who would be in a position to dictate our covered services and therefore, how and what we schedule. This would affect our ability to allocate the substantial time to our patients which we find to be a necessity in our practice. In other words, we work for our patients and not the insurance companies.
We do however encourage each patient to utilize their dental insurance coverage (if applicable) and interestingly enough, while the coverage seems to be quite a bit less when going to an “out of network” office, it ends up being basically the same benefits when you use them at Medicine Wheel.
Let us explain how… It is a discouraging fact that for most people today, dental insurance benefits are the same as they were in the 70’s. The biggest change (other than dental advancements) is the cost. Unfortunately this sector of insurance has not evolved with the high fluctuation in dental office’s overhead. Most insurance companies will cover $1,000 – $1,500 annually (there are some exceptions for slightly better coverage). Some have a one time deductible and some do not.
Typically coverage is based on the following categories:
Preventative; cleanings, exams, x-rays, etc.– 100%
Basic Restorative; fillings, some periodontal & oral Surgeon services, etc. – 80%
Major Restorative; crowns, bridges, implants, more major periodontal & oral Surgery, etc.) – 50%
*This is based upon the insurance company’s fee schedule
What most people are traditionally used to is not paying up front, the insurance pays what they pay, and then the patient receives a bill for the remainder of the balance. At Medicine Wheel Dental we collect payment when a service is rendered, we then submit to dental insurance companies who pay based on the same tiered system. This payment goes to the patient directly, and at the end of the year the patient still receives their $1,000 – $1,500 as a capped benefit regardless of how much dental work they had for that year.
The reality is, patients receive the same capped annual coverage as they do with an “in network” dental office.
Medicine Wheel Dental has invested into a state of the art insurance submission service so that our clients with out of network dental insurance benefits receive the insurance company’s reimbursement within the shortest amount of time currently available without compromising the level of care we can offer.
It is for the reasons above that Medicine Wheel Dental feels that this system is a “win, win” We do understand that dental insurance protocols, terminology, and coding can be a complex and time consuming process. Because your time is important to us, we are happy to offer the service of insurance submission and follow up at no additional charge to you.
One of our little ways of saying THANK YOU to all of our friends at Medicine Wheel.
“Don’t wait; utilize this year’s dental insurance coverage today.
Most policies renew January first and schedules are filling up quickly”
In case you missed the Natural Awakenings article –
Ask The Doctor
Dr. Swidler was interviewed by Traci Moore to answer some dental questions that are important to Natural Awakenings’ readers. We listed the article below, but if you would like, you can download the entire article here.
Dr. Steven Swidler of Medicine Wheel Dental received his Bachelor of Science degree from the University of Illinois and his dental degree (DDS) from the University of Illinois dental school in 1972. After two years in clinical and private practice in Chicago, Dr. Swidler relocated to Tucson, where he became deeply committed to holistic and integrative dental approaches. He lectures nationally and internationally on topics related to innovative dental therapies. Dr. Swidler answers Natural Awakenings’ questions about alternative dentistry.
Are there any natural alternatives to a root canal?
When a tooth becomes painful and shows early signs of dying, dentists generally either perform a root canal or extract the tooth. There is, however, an alternative treatment that involves the use of a natural, rice bran-based material. This material contains 70 natural antioxidants and calms nerve tissue. In a 12-year clinical study, the material has had a greater than 80% success rate keeping teeth living and healthy when three conditions are present: the tooth is still vital; the nerve, even if exposed, is still alive; and the anesthetic is effective in numbing the tooth.
What is TMJ dysfunction and how is it treated?
The temporomandibular joint (TMJ) is the jaw joint located on either side of your head, just in front of your ear. When a patient’s bite is “off,” the jaw may become misaligned, which can create headaches, a tight neck, a stiff or painful jaw, and even shoulder, back, hip or knee pain. An expanded bite evaluation during a dental exam can determine how a jaw/bite problem may be affecting the body’s alignment and function. With the aid of dental appliances, patients can gradually re-establish a neutral jaw position so their TM joint can heal, relieving more than 80% of overall symptoms within one to five months. Many other modalities, like one-on-one yoga, massage, and cranial osteopathy can also help eliminate strain or injury and strengthen new body movement patterns.
Are silver fillings really a health concern?
Often mistakenly called “silver” because of their appearance, these fi llings are actually amalgams, composed of 50% mercury. Mercury is the number one neurotoxin. The free ions in mercury can move through tissue and into the blood, cross the blood brain and placental barriers, and distribute mercury throughout the body. When a person with a mercury amalgam fi lling (no matter the age of the fi lling) chews food or drinks a hot beverage, a measurable amount of mercury vapor is emitted. If you decide to have your amalgam fi llings removed, remember that mercury amalgams should be removed only with very safe protocols to prevent you from being exposed to even higher levels of mercury. Speak to your dentist about protective protocols for amalgam removal before considering this action.
Do you recommend dental implants?
In general, dental implants are an excellent method for replacing missing teeth. However, it’s important to consider that the body’s white blood cells constantly fight bacteria and viruses in the blood. Because these bacteria and viruses often settle around foreign implants in the body (knees, hips, jaws, etc.), some dentists will prescribe antibiotics after dentistry in an attempt to prevent bacteria from entering the blood stream and settling around these foreign materials. Until a ceramic or other material is developed that stops unhealthy bacteria from gathering in no-circulation areas, dental implants, despite their obvious benefi ts, may pose a health concern.
In case you missed The New Southwest article –
Dr. Swidler contributed to the sections regarding: Stress: Easing Up on Life and Spirit: Beyond the Body
Stress: Easing Up on Life
Recognizing how intricately each part of the body functions in connection to every other part is where these holistic physicians place their emphasis. “Happiness is influenced by a lot of things. You can take someone who eats well but if they live under tremendous stress, it’s difficult,” says Cabin.
Yantra Yoga Image
Stress is a normal physical reaction to threatening situations, according to the Mayo Clinic. However, what may be a normal, healthy reaction on occasion becomes a health risk when one’s lifestyle generates stress on a consistent basis.“Stress symptoms can affect your body, your thoughts and feelings, and your behavior,” warns the Mayo Clinic.
One stress symptom people are often unaware of is jaw clenching or grinding while they are sleeping. Jaw clenching doesn’t just jeopardize your dental health. But it can actually overload the body’s entire system and cause pain throughout your entire body, according to Steven Swidler, DDS, owner of Medicine Wheel Dental & Wellness Center, a holistic dental practice in Tucson.
“I tell people, lips together, jaw relaxed,” Swidler says. “he only time your teeth are touching is chewing or swallowing. Think of it as a tuner on a radio. When your jaw is relaxed, the signal is on the right station, but when you bite down, you’re in between stations and there’s a lot of static going to all your muscles, all your organs.” For example, he adds, simply by adjusting your jaw, you can notice relief in lower back pain.
Spirit: Beyond the Body
“I find that once a person is back in balance, in a state of wellness, they are able to choose for themselves the next steps to take to stay in health,” says Phelps.
It’s true that adjusting diet and addressing stress management will
take you far in your pursuit of health and happiness, but it’s also crucial to not forget the spiritual component of total wellness.
“I don’t think that you can be happy without having some sort of spiritual understanding of the world,” says Ackerly. “It may be religion, it may be family, it may be a job – but that sense of meaning is really important.”
Swidler begins his day with prayer for guidance, and Cabin practices his own form of spirituality as artfully as he practices holistic medicine. Many of the professionals cited in this article are also strong advocates of regular yoga and meditation for bringing balance to even the most hectic of lifestyles.
Click here to read the entire article from The New Southwest.
In case you missed the New Southwest article –
Healthy teeth reflect a healthy body, mind
The New Southwest featured Dr. Swidler in this article reflecting on total body wellness. Posted here is an excerpt, but the article is terrific, click here to read it in its entirety.
Healthy Teeth - Healthy Body
But what if we experienced dentistry as a portal to high-level wellness for the whole body? Mind? Spirit? What if we said, “My knee is killing me and I’m exhausted all the time. I wonder if my body and jaw are misaligned?” Or we left a dental office feeling refreshed, on the path to reinvigorated head to toe health?
“What would [health] look like at its best?” is a personal challenge that has guided Dr. Steven Swidler, D.D.S. from traditional premed studies to holistic dentistry.
Holistic dentistry provides support for the whole human being, honoring the vital connection between the spiritual, physical, and emotional. In its most primitive form, it “recognizes there’s a person attached to the tooth. We’re not here to fix the tooth and traumatize the person,” says Swidler, founder of Medicine Wheel Dental, an integrative dental practice.
The need to honor his own spirit, mind, and body is what led Swidler into dentistry in the first place. “You know how you start on a path in life and you feel like it’s taking you, instead of you choosing it?” he asks. He experienced that when he was a premed student at the University of Illinois, so he stepped back and envisioned all the things he truly loved. “Biology, helping people, arts and crafts. I wanted to be my own boss.” What could possibly meet all those requirements? Dentistry. Of course.